Accuracy of final-year paramedic students' ECG interpretation and referrals for transient loss of consciousness, per the NICE CG109 guidelines

INTRODUCTION: Paramedics in the UK independently assess patients with transient loss of consciousness (TLOC) in community settings. The UK’s National Institute for Health and Care Excellence publish guidance on assessment of TLOC (NICE CG109), recommending ECG interpretation to identify red-flag abnormalities that warrant referral. This study assessed whether final-year university paramedic students meet these recommendations uniformly across different ECG patterns. MAIN HYPOTHESIS: Participants will identify Brugada Syndrome (a required but difficult to recognize ECG pattern) with a lower success rate than Ventricular Tachycardia (an easily recognizable pattern). METHODS: An online study tested third-year paramedic students’ ECG interpretation skills and referral decisions across 18 UK higher educational institutions. Students’ subjective confidence ratings were also measured. RESULTS: Participants identified ventricular tachycardia (94.7%) and STEMI (89.4%) well but struggled with Brugada sign (51.5%), ventricular hypertrophy (43.9%), and Wolff-Parkinson-White (40.9%). While most abnormalities were referred despite misidentification, some high-risk patterns were not recognized and, more concerningly, often not referred. Lower self-reported confidence in an ECGs interpretation was associated with a higher likelihood of referring normal traces. CONCLUSION: A mismatch exists between final year paramedic students' ECG interpretation ability and the NICE CG109 expectations. While participants generally took a cautious approach, failure to refer some critical ECG abnormalities raises concerns. Educational programs and CG109 should align better to ensure paramedics reliably recognize and act on important ECG findings.